NCC211380_NOI Signed Certification_20210331

DocuSign Envelope ID: BC691 E25-0687-4556-9BCF-39021298A1 F3
NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
Cr I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
Cv� The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
IV If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala): Belmont, NC Chick-Fil-A
Specific Lot Numbers (must match Alb):
Legally Responsible Organizational Entity (must match 81): Chick-fil-A, Inc.
Legally Responsible Person (must match 82 & 83): John Mark Wood
Title of Legally Responsible Person (must match 83b): Director
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
ne Number: 404-765-8000
Signature of Legally Responsible Person or Authorized Individual
3/3/2021 1 10:27 PM EST
Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCGO10000 permit.

Docu5�".
6 S E C U R E 6
Certificate Of Completion
Envelope Id: BC691 E25068745569BCF39021298A1 F3
Status: Completed
Subject: Please DocuSign: NCG01-eNOI-Certification-Form-20210212-DEMLR-SW (Belmont, NC Chick-Fil-A).pdf
Source Envelope:
Document Pages: 1 Signatures: 1
Envelope Originator:
Certificate Pages: 1 Initials: 0
Sally Pierce
AutoNav: Enabled
5200 Buffington Road
Envelopeld Stamping: Enabled
Atlanta, GA 30349
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
[e-mail]
IP Address: 45.30.44.92
Record Tracking
Status: Original
Holder: Sally Pierce
Location: DocuSign
3/3/2021 10:24:27 PM
sally. [e-mail]
Signer Events
Signature
Timestamp
John Mark Wood
by:
Sent: 3/3/2021 10:26:05 PM
[e-mail]
EDII"Sil"Id
6 1L M.A (N4
Viewed: 3/3/2021 10:27:36 PM
Chick-fil-A, Inc.
BFA1466A3F32463...
Signed: 3/3/2021 10:27:47 PM
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre -selected Style
Using IP Address: 76.17.118.245
Signed using mobile
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
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Hashed/Encrypted
3/3/2021 10:26:05 PM
Certified Delivered
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3/3/2021 10:27:36 PM
Signing Complete
Security Checked
3/3/2021 10:27:47 PM
Completed
Security Checked
3/3/2021 10:27:47 PM
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